Postoperative Management

The recipient should be established on immunosuppression immediately following surgery. For the first several days posttransplant, only select medications, included Tacrolimus should be administered via the GI tract. In circumstances where Tacrolimus absorption via the GI tract has been questionable, sublingual administration can be utilized. In most circumstances Tacrolimus is the main immunosuppressive drug. However, if the patient is intolerant of Prograf, consideration can be given to other immunosuppressive regimens based on Neoral. Sirolimus, especially in combination with Tacrolimus, has improved patient and graft survival and is now being incorporated into most immunosuppressive protocols. Steroids are also included in the postoperative immunosuppressive regimen. While induction with OKT3 or ATGAM has generally been avoided because of the higher incidence of PTLD associated with intestinal transplantation,18 some centers have been reevaluating their role. Alemtuzumab (CAMPATH-1H)', an anti-CD52 mAB, has also been used by some centers although its safety and efficacy in intestinal transplantation has not yet been clearly established. Monoclonal anti-IL2 receptor antibodies (Basiliximab, Daclizumab) are currently being used for most intestinal transplants, as they appear to provide benefit. While some programs have included mycophenolate mofetil,22 others have avoided it because of its association with gastrointestinal side effects. Prostaglandin E1 is commonly administered intravenously while the patient is in the hospital, both for its ability to improve the small bowel microcirculation and its potential immunosuppressive effects. Broad-spectrum intravenous antibiotics are usually continued for at least 1 week following the transplant.

It is imperative to maintain prophylaxis for cytomegalovirus (CMV) and Epstein Barr, virus (EBV) infections post operatively particularly where the donor is positive for CMV or EBV and the recipient is negative. CMV prophylaxis is best accomplished with Gancyclovir, although CMV immune globulin (Cytogam) has also been used. Acyclovir, which is less effective than Gancyclovir for CMV, is effective prophylaxis for EBV. Intravenous immune globulin (IVIG) is also used by some centers as EBV prophylaxis.

In the immediate postoperative period it is essential to check hemoglobins regularly for evidence of bleeding. It is also important to monitor serum pH and lactate levels to detect any evidence of intestinal ischemia or injury. Prograf levels should be followed daily and doses adjusted to achieve a serum level of 20-25 ng/ ml in the early posttransplant period.

Approximately 5 days post transplant, if all is stable, an upper GI contrast study should be performed to ensure that there is no leakage or other gross abnormality in the newly established gastrointestinal tract. If the upper GI contrast study reveals no contraindication, tube feed should be initiated slowly but can usually be advanced to provide full nutritional support within a couple of days. The ideal features of an enteral feeding solution to be established in a new intestinal transplant recipient are that it: (a) provides maximum calories with minimal volume

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